What are the differences in pharmacology, including mechanism of action, pharmacological effects, indications, contraindications, side effects, and dosage, among local anesthetics such as lidocaine, bupivacaine (Marcaine), EMLA (Eutectic Mixture of Local Anesthetics), and other agents?

Comparison of Local Anesthetics: Pharmacology and Clinical Applications

Mechanism of Action

All local anesthetics work by the same fundamental mechanism: stabilizing neuronal membranes through inhibition of ionic fluxes required for nerve impulse initiation and conduction. 1 This applies uniformly to lidocaine, bupivacaine (Marcaine), and all other agents discussed below, regardless of their chemical classification as amino-esters or amino-amides. 2

Classification by Potency and Duration

Local anesthetics are best understood through a three-tier classification system:

• Low potency, short duration: Procaine and chloroprocaine (30-90 minutes) 3, 4
• Intermediate potency, moderate duration: Lidocaine, mepivacaine, prilocaine (90-240 minutes) 3, 4, 5
• High potency, long duration: Bupivacaine (Marcaine), ropivacaine, levobupivacaine, tetracaine (180-600 minutes) 3, 4, 5

Individual Agent Profiles

Lidocaine

Lidocaine is the prototypical intermediate-duration local anesthetic with rapid onset (less than 2 minutes for infiltration) and reliable efficacy across all regional techniques. 1

Pharmacological Effects

• Provides pulp anesthesia averaging 60 minutes with infiltration and 90 minutes with nerve blocks 1
• Soft tissue anesthesia lasts approximately 2.5-3.5 hours depending on technique 1
• Completely absorbed following parenteral administration, with absorption rate varying by injection site and vasoconstrictor presence 1
• Metabolized rapidly by the liver with elimination half-life of 1.5-2.0 hours 1
• 60-80% protein bound at therapeutic concentrations 1

Maximum Dosing

• Without epinephrine: 4.4-4.5 mg/kg (maximum 300 mg) 3, 6
• With epinephrine: 7.0 mg/kg (maximum 500 mg) 3, 6
• For IV regional anesthesia: reduce to 3-5 mg/kg 3, 6
• Pediatric patients <6 months: reduce amide doses by 30% 3, 6

Clinical Indications

• First-line agent for infiltration anesthesia, minor nerve blocks, and dental procedures due to rapid onset 4
• Preferred for procedures requiring moderate duration (1-3 hours) 4
• Suitable for epidural anesthesia when intermediate duration is adequate 4

Contraindications

• Known hypersensitivity to amide-type local anesthetics 1
• Hypersensitivity to any formulation components 1

Side Effects and Toxicity

• CNS toxicity threshold: objective adverse manifestations appear above 6.0 μg/mL free base 1
• Convulsive threshold: 18-21 μg/mL in animal models 1
• Cardiovascular depression with excessive blood levels 1
• CNS excitation followed by depression is the most common toxicity pattern 5

Bupivacaine (Marcaine)

Bupivacaine is the gold standard long-acting local anesthetic, particularly for subarachnoid anesthesia, but carries significant cardiotoxicity risk requiring strict dose adherence. 7

Pharmacological Effects

• Duration of action: 180-600 minutes depending on technique and concentration 3, 4
• Slower hepatic metabolism compared to other amides, resulting in prolonged clearance 2
• High lipid solubility correlates with increased potency and cardiotoxicity 7

Maximum Dosing

• Without epinephrine: 2.0-2.5 mg/kg (maximum 175 mg) 3, 8, 6
• With epinephrine: 3.0 mg/kg (maximum 225 mg) 3, 6
• Pediatric maximum: 2.5 mg/kg for most blocks, 3.0 mg/kg with epinephrine 3, 8
• Neuraxial maximum: 2.5 mg/kg provides substantial safety margin 6

Procedure-Specific Dosing (0.25% solution)

• Wound infiltration/peripheral nerve blocks: 1 mL/kg (2.5 mg/kg maximum) 8
• Caudal block (pediatric): 1.0 mL/kg 8, 9
• Lumbar epidural: 0.5 mL/kg (maximum 15 mL initially) 8, 9
• Thoracic epidural: 0.2-0.3 mL/kg (maximum 10 mL initially) 8, 9
• Fascia iliaca/femoral nerve block: 0.2-0.5 mL/kg 8
• Intrathecal labor analgesia: 2.5 mg with fentanyl 15 μg 9
• Continuous infusion: 0.1-0.3 mL/kg/h of 0.25% solution 8

Clinical Indications

• Best indication: subarachnoid (spinal) anesthesia, especially in hyperbaric solution 7
• Epidural anesthesia for cesarean section (equivalent to newer agents) 7
• Peripheral nerve blocks when prolonged analgesia is required 7
• Postoperative pain management via continuous infusion 8

Contraindications

• Known hypersensitivity to amide-type local anesthetics 1
• Should NOT be used for IV regional anesthesia due to cardiotoxicity risk 3

Side Effects and Toxicity

• Well-known cardiotoxicity and CNS toxicity, more severe than other local anesthetics 7
• Cardiovascular collapse can occur with inadvertent intravascular injection 3
• Requires lipid emulsion rescue: 1.5 mL/kg of 20% lipid over 1 minute, then 0.25 mL/kg/min infusion 6

Special Considerations

• Reduce dose in elderly, debilitated, or patients with cardiac/hepatic disease 9
• Calculate maximum dose before administration to prevent overdose 3, 6
• Aspirate frequently to avoid intravascular injection 3

EMLA (Eutectic Mixture of Local Anesthetics)

EMLA is a topical formulation combining lidocaine 2.5% and prilocaine 2.5% for non-invasive surface anesthesia. While not explicitly detailed in the provided guidelines, this represents a distinct application category.

Clinical Indications

• Topical anesthesia for intact skin prior to venipuncture or minor dermatologic procedures
• Requires 60-90 minutes application time for adequate dermal penetration
• Not suitable for mucous membranes or broken skin

Alternative Long-Acting Agents

Ropivacaine

• Maximum dose: 3.0 mg/kg (allows 1.5 mL/kg of 0.2% solution) 8, 6
• Preferred alternative when larger volumes needed than bupivacaine allows 8
• Potentially improved safety profile compared to bupivacaine 8
• Similar duration to bupivacaine (180-600 minutes) 3

Levobupivacaine

• Maximum dose: 3.0 mg/kg 6
• S-enantiomer of bupivacaine with reduced cardiotoxicity 8
• Similar efficacy to racemic bupivacaine 8
• Not available in United States 3

Critical Safety Principles

Dose Calculation Algorithm

Always calculate maximum allowable dose in mg/kg BEFORE administration to prevent toxicity. 3, 6

1. Determine patient weight (actual weight for normal BMI, ideal body weight for obesity) 8
2. Calculate maximum mg dose based on agent and epinephrine use 3, 6
3. Convert to maximum volume using concentration conversion (Table 4 reference) 3
4. Reduce by 30% if infant <6 months 3, 6
5. Reduce further if elderly, cardiac disease, hepatic disease, or pregnancy 9, 10

Epinephrine Effects

• Adding epinephrine 1:200,000 increases maximum safe doses by reducing systemic absorption 3, 6, 4
• Effect is most pronounced with shorter-acting agents (lidocaine, mepivacaine) 4
• Less benefit with intrinsically long-acting agents (bupivacaine) in epidural techniques 4
• Benefit lost with inadvertent intravascular injection 6

Injection Technique

• Aspirate frequently before and during injection to minimize intravascular injection risk 3
• Use incremental dosing for large volumes (3-5 mL increments for epidural) 6
• Lower doses required in highly vascular areas 3

Monitoring Requirements

• Document vital signs at least every 5 minutes when high doses used 3, 6
• Continuous oxygen saturation and heart rate monitoring required 3
• Enhanced sedative effects occur when maximum doses combined with opioids or sedatives 3

Local Anesthetic Systemic Toxicity (LAST) Management

If LAST suspected, immediately call for help and alert nearest facility with cardiopulmonary bypass capability. 3, 6

1. Ventilate with 100% oxygen 3
2. Administer 20% lipid emulsion: 1.5 mL/kg bolus over 1 minute 6
3. Start lipid infusion: 0.25 mL/kg/min until circulation restored 6
4. Avoid vasopressin, calcium channel blockers, β-blockers 3
5. Continue CPR—may require prolonged resuscitation 3

Common Pitfalls to Avoid

• Never exceed maximum mg/kg doses even if "usual volumes" seem small—toxicity is dose-dependent, not volume-dependent 3, 10
• Do not use bupivacaine for IV regional anesthesia—cardiotoxicity risk is unacceptable 3
• Remember to reduce amide doses by 30% in infants <6 months—this is frequently overlooked 3, 6
• Calculate doses based on ideal body weight in obese patients—using actual weight leads to overdosing 8
• Recognize that liver dysfunction doubles elimination half-life—reduce doses for repeated/continuous administration 1, 10
• Do not assume epinephrine always increases safety—it provides no protection against direct intravascular injection 6